1

Gender Differences in Treatment Entry and Retention Among

Prisoners With Substance Use Histories

Bernadette Pelissier, Ph.D.

Federal Bureau of Prisons

The views expressed herein are those of the author and do not
necessarily reflect the view of the Federal Bureau of Prisons.
 Gender Differences in Treatment Entry and Retention Among
Prisoners With Substance Use Histories

Abstract

Objectives: This paper examined gender similarities and differences in the predictors of
treatment entry and the combination of treatment entry and completion. Methods: The sample
consisted of 2,219 male and female program participants. Maximum likelihood probit estimation
was used to identify background and attitudinal characteristics predictive of treatment entry and
retention. Results: There were gender similarities and differences in predictors of treatment entry
and the combination of treatment entry and completion. Many of the factors which attract
individuals to treatment are the same which keep individuals in treatment. Conclusions: The
greatest consistency in results when making gender comparisons and when comparing predictors
of treatment entry to predictors of treatment entry and completion was for attitudinal predictors,
namely motivation to change.

Keywords: Treatment entry, Treatment retention, Drug treatment, Incarcerated drug users

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 Drug abuse has been identified as the nation's most serious health problem because it

strains the health care system and has negative effects on families, the economy and public safety

(1). The considerable growth in prison populations during the last decade has been fueled by

individuals with substance abuse problems (2). The increasing incarceration rate now results in

over 550,000 individuals returning to communities, most of these being untreated despite having

drug abuse histories (3). Thus, the public health role of the criminal justice system is now of

greater importance (4).

Although research shows treatment to be effective, little is known about how

effectiveness may be enhanced through a better understanding of treatment entry and retention (4,

5). An understanding of treatment entry in particular is important because only a small number of

substance users enter treatment (5, 6). Most of the attention within the field of substance abuse

has been on treatment retention and only recently has attention been paid to help-seeking

behavior (6, 7). Increasing appropriate help-seeking behavior by substance users can help reduce

the misutilization of other health services, particularly by women (6, 8, 9).

Our understanding of treatment entry and retention within prison settings is very limited

because there are few prison-based studies of treatment retention (10, 11) and no studies of

treatment entry. The limited studies of treatment entry among community samples of various

types of drug abusers (7, 12-19) find little consistency in the background characteristics

predictive of treatment entry (5). However, higher levels of problem severity are frequently

associated with treatment volunteerism. In contrast, studies which include dynamic predictor

factors find that individuals with higher motivation are more likely to enter treatment (19).

The larger body of literature on treatment retention (10, 11) is similar to that on treatment

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entry: sociodemographic factors are inconsistent predictors (11, 20-30) and are generally

not large predictors of retention (6, 10). Different measures of motivation are consistently related

to treatment retention (10, 25, 26, 29, 31-34).

Included in recent treatment retention literature is a growing awareness of gender

differences in program needs that may differentially affect retention for women (35, 36). Women

are more likely than men to enter treatment (17) and engage in drug treatment (37). Some studies

show women as less likely than men to remain in drug treatment (23, 27, 28) whereas others do

not find any relationship (38, 39). Women's programs which offer more specialized services or

interventions (35, 36, 40-42) have better retention rates. Research, however, has not

systematically addressed the question of gender differences in treatment entry and treatment

retention.

PURPOSE OF STUDY

The purpose of this study is to examine treatment entry as well as the combination of

treatment entry and completion. Previous research has seldom examined prison populations and

there is little information on gender differences. Therefore, this study examines individuals

incarcerated in federal prisons and separately examines men and women. Lastly, this study

assesses whether the processes by which individuals enter treatment are similar to those by which

individuals enter and complete treatment.

Retention is conceptualized as program completion because federal prison programs have

a defined time frame. Unlike previous research which examines predictors of retention among

individuals already admitted to a program, this study examines the combination of treatment

entry and retention. By not taking into account sample selection into treatment (volunteering),

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this study does not assume that the causal processes between volunteering for treatment and

volunteering for and completing treatment are dissimilar. This study first examines predictors of

treatment entry among those eligible for treatment and continues by examining predictors of

treatment entry and completion.

METHODS

Research Participants

The subjects were participants in an evaluation of the Federal Bureau of Prisons' (BOP)

residential drug abuse treatment programs. Participants were from 4 female and 16 male

unit-based programs and were admitted to treatment between 1991 and 1995. Three of the

programs consisted of 1,000-hour programs which offered treatment over a 12-month period.

The remaining 17 consisted of 9-month, 500-hour programs. The cognitive-behavioral treatment

programs emphasized relapse prevention and criminal lifestyle issues. Admission criteria

required that inmates were within 36 months of release and had a moderate to severe substance

use problem. Treatment volunteers were not able to choose between the 12-month and 9-month

program: the choice was limited to the program available at the specific prison.

Comparison subjects were randomly selected from among those individuals who met the

criteria for admission to the programs but who did not volunteer for treatment. They were

selected between 1993 and 1995 from among inmates at 40 prisons who had less than 15 months

remaining on their sentence to ensure that they would not become treatment participants. The

overall sample was comprised of 2,219 participants. The 1,734 men comprised 1,189 treatment

participants and 545 comparison participants. The 485 women comprised 300 treatment

participants and 185 comparison participants.

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 Measures

Predictors included background and attitudinal characteristics found to be predictive of

treatment entry or treatment retention in other studies, characteristics relevant to gender

differences, and attitudinal measures with theoretical relevance to the drug treatment programs

(43). Data were obtained from the BOP's automated data base and from inmate interviews and

surveys obtained using informed consent and research procedures approved by the BOP

Institutional Review Board. Inmates received their normal work assignment pay while

participating in research to prevent refusals.

Demographic characteristics included race, ethnicity, years of education, and ever having

been legally married. Indicators of criminal history included: severity of current offense, history

of violence, age at time of most recent commitment, age when first arrested, and sentence length.

In addition to employment status in the month before incarceration, a variety of family

background items were included: family ties, spouse ever had a substance use problem, plans to

live with children under 18 after release, history of physical abuse before the age of 18, and

history of sexual abuse. Substance use history was categorized by type of drug(s) ever used on a

daily basis. Other items included history of drug treatment and attempts to stop using illegal

drugs for at least 30 days. Lifetime DSM-III-R diagnostic information for depression and

antisocial personality was obtained using the automated Diagnostic Interview Schedule which

has been found to be reliable and valid (44, 45).

The four scales of the Change Assessment Scale were used to measure internal

motivation (46). Individuals must realize they have a problem (i.e., not deny their problem -

precontemplation), contemplate acting to address the problem (contemplation), take specific

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action (action) and after taking action, use strategies to maintain changes (maintenance). Other

attitudinal measures included the Hope Scale (47), which is comprised of two subscales. The

first, agency, refers to a person's sense of successful determination in relationship to reaching

one's general goals. The second, pathway, refers to a person's sense of being able to plan to meet

one's goals. The last attitudinal measure consisted of the planful problem-solving subscale of The

Ways of Coping Questionnaire (48).

A measure of external incentive indicated whether or not an individual was eligible for up

to a one-year sentence reduction for successful program completion. This incentive became

available mid-course in data collection, and thus it was possible to identify whether or not the

individual volunteered before or after the time when this incentive was available and how much

time he/she could have benefitted: no time, less than 5 ½ months off, or more than 5 ½ months

off.

Treatment completion was defined as completing either the 9- or 12-month program.

Individuals did not complete treatment because they were discharged for disciplinary reasons,

were unable to complete treatment due to administrative reasons (e.g., released before

completion), or dropped out. The analyses differentiated the 9- and 12-month programs because

it is possible that completing a 12-month 1,000-hour program is more difficult than completing a

9-month, 500-hour program.

Design

Maximum likelihood probit estimation procedures were used to provide estimated

probabilities for the two outcomes. Choosing a probit procedure rather than a logit procedure is

one of convenience because the results derived from both are very similar (49, 50).

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Methodological details are available in a report with similar analyses (43).

RESULTS

Effects vector coding, where each coefficient represents the contrast of a specific category

with the adjusted grand mean, was used for categorical variables. However, for pre-incarceration

drug use dummy variable coding was used to contrast each category with the referent category of

no daily substance use in the year before incarceration.

A positive probit coefficient implied a greater likelihood of entering or completing

treatment whereas a negative coefficient implied a reduced likelihood. The Wald chi-square

test (51) was used to test for differences between coefficients when a coefficient was significant

for either or both genders. For simplicity, the results reported in Tables 2 and 3 include only

those variables that were significant for either gender. Results for treatment entry do not report

for the coefficient representing the type of program - 12-month or 9-month - because individuals

were not able to choose between the two types of programs. Table 1 provides a profile of the

characteristics of men and women found to be significant in one or more models. Although

women had more problems in employment and depression and were more likely to have a history

of physical abuse, women had higher levels of internal motivation.

Entering Treatment

Table 2 contains the results for treatment entry. Neither race nor ethnicity was related to

treatment entry. However, both men and women of higher education levels were less likely to

enter treatment. An effect was found for offense of moderate severity but the direction of the

effect for men was opposite of that for women. Women with a moderate severity offense were

less likely to enter treatment but men with a moderate severity offense were more likely to enter

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treatment. The Wald-chi square test for the difference between coefficients was significant

(x2=12.5 p<.05).

Opposite effects for family ties were found. Women with "average/good" family ties were

more likely to enter treatment but men with such family ties were less likely to enter treatment.

Women who were not in the labor force before incarceration were more likely to enter treatment.

In contrast, employment history was unrelated to treatment entry for men. The Wald chi-square

test showed both of these coefficients to differ between men and women: x2=13.05 for family ties

and x2=4.14 for not being in the labor force.

Among men, there were no significant effects for type of substance use. In contrast,

among women, 2 categories of substance use were related to treatment entry. Women who used

marijuana only on a daily basis before arrest were less likely to enter treatment but women who

used alcohol only were more likely to enter treatment. The Wald chi-square test showed that only

the coefficient for alcohol use (x2=5.68) indicated a significant gender difference.

Antisocial personality and depression diagnoses were related to treatment entry for

women but not for men. Women who did not have either diagnosis were more likely to enter

treatment but women who had a diagnosis of depression, either alone or with antisocial

personality, were less likely to enter treatment. None of these coefficients differed significantly

from those for men.

Both men and women planning to live with minor children after release were more likely

to enter treatment. Women who had been physically abused before the age of 18 were more

likely to enter treatment. This family background characteristic was not significant for men and

the test of differences between coefficients for men and women was not significant.

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 The results for the Change Assessment Scale were similar between men and women. Men

and women with high precontemplation scores (unaware of drug problem) were less likely to

enter treatment; whereas, individuals with high maintenance scores (works to maintain the gains

previously made and prevent relapse) were more likely to enter treatment. Among men only,

those with high contemplation scores (recognizes problem and is contemplating taking action)

were more likely to enter treatment. The coefficient for contemplation among women was

marginally significant (at the conventional .05 level) and in the same direction (but the

coefficients did not significantly differ).

The results for the measure of external incentive - the year- off incentive - differed

between men and women. Among men, those who could not have received a sentence reduction

and those who could have received a reduction of 5 ½ months or less were less likely to enter

treatment. Although the coefficients were not significant for women, the chi-square test did not

show that the coefficients for men were significantly different from those for women.

Treatment Entry and Completion

Approximately 78% of the men and 64% of the women completed treatment and the

program completion rate was lower for the 12-month program participants. Among men, 74% of

the 12-month participants completed treatment as compared with 80% of the 9-month

participants. Among women, the percentages were 60% and 67%, respectively.

The results reported in Table 3 show that race and ethnicity were not related to entering

and completing treatment. Both men and women with a greater severity offense were more likely

to complete treatment. In contrast, among women only, those with a moderate severity offense

were less likely to complete treatment. The non-significant coefficient for men was found to

10
differ significantly from that of women (x2=7.44) and was in the opposite direction.

The chi-square test showed that the apparent gender differences for other indicators of

criminal history were sustained only for age of first arrest. Women who were older at the age of

their first arrest were more likely to complete treatment. The coefficient for men, although not

significant, was in the opposite direction (x2= 9.40). Men with a recent violent history and those

with longer sentence lengths were less likely to complete treatment whereas those who were

older at time of current commitment were more likely to complete treatment.

Family ties were related to treatment completion among men but not women. Men with

average/good family ties were less likely to complete treatment. The coefficient for women

differed from that of men (x2=9.39) and, although not significant, was in the opposite direction.

There were no significant effects for either men or women for type of substance use.

However, among men only, those with a history of drug treatment were less likely to complete

treatment. The coefficient for women was not significant but was significantly different from that

for men (x2=19.59).

Men and women without either a diagnosis of antisocial personality or depression were

more likely to complete treatment. Among women only, those with a diagnosis of antisocial

personality only were more likely to complete treatment whereas those with both diagnoses were

less likely to complete treatment. The chi-square test showed that only the coefficient for a

diagnosis of antisocial personality differed between men and women (x2=5.12).

Men who planned to live with minor children after release were more likely to complete

treatment. While no such effect was apparent for women, the chi-square test showed the

coefficients did not differ.

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 Both men and women with high precontemplation scores were less likely to complete

treatment; whereas, individuals with high maintenance scores were more likely to complete

treatment. Among men only, those with higher contemplation scores were more likely to

complete treatment. This coefficient was not significant for women and did not significantly

differ from that for men.

Among men only, external incentives were related to treatment completion: those who

could not have benefitted from the sentence reduction provision were less likely to complete

treatment. The coefficient was not significantly different from that for women. Among both men

and women, individuals who entered a 12-month program were less likely to complete treatment.

DISCUSSION

The results of this study suggest that greater attention should be paid to treatment entry,

particularly in prison settings where treatment is often voluntary and where individuals who enter

treatment are very likely to complete treatment. Because retention is higher than in non-prison

based treatment programs and an increasing number of drug users are incarcerated, a question of

greater importance is whether the intended or ideal target population is being reached? Criminal

justice settings currently provide an opportunity to ameliorate public health problems, such as

acquired immunodeficiency syndrome (AIDS) associated with drug use, because a large

percentage of substance users are involved in the criminal justice system.

Although the federal prison drug treatment programs do not target any specific

subpopulation of substance abusers, the findings point to policy modifications which could better

address the issues of all those needing treatment. The importance of internal motivation for both

treatment entry and retention among both genders suggests the broader application of

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interventions which have been found to increase internal motivation. Motivational enhancement

intervention research has shown that clinicians can elicit the motivation to change from the client

(52-54) and that motivational interviewing can increase session attendance and the likelihood of

treatment completion (54, 55). The use of such interventions could help induce motivation

among individuals entering treatment. Individuals with initial low levels of motivation could be

diverted to motivational interviewing pretreatment program tracts. Alternatively, where treatment

resources are limited, efficiency may be enhanced by requiring that individuals reach a minimal

threshold of motivation before admission.

Both internal and external motivations draw individuals into treatment. Previous research

on external motivation has taken place primarily within the context of community-based

programs where it is often defined as coerced treatment (e.g., legal pressure) (56, 57). However,

little is known about external incentives which involve rewards such as sentence reductions that

often occur in prison settings. The findings suggest that despite such "carrots" as sentence

reduction, internal motivation is nonetheless very important because it was a predictor of

treatment entry and treatment completion even in this context where external incentives were

available.

The finding that women with neither a diagnosis of depression nor one of antisocial

personality disorder were more likely to enter treatment occurs within a context of increasing

recognition of the needs of substance abusers with co-occurring disorders (58, 59). Treatment

effectiveness may be enhanced by ensuring that individuals with co-occurring psychiatric

problems and drug use enter and complete treatment. The greater percentage of women with a

diagnosis of depression is consistent with previous research: women use drugs to alleviate

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physical or emotional pain or to cope with depression (60-63). Previous findings also show that

women are more likely to view their problems in terms of health concerns and psychological

problems (8, 9) and are motivated to enter treatment because of psychological and social

pressures (64). Thus, if drug treatment is perceived as focusing initially on substance use rather

than the psychological distress that might be motivating individuals to seek treatment,

individuals may be less likely to enter treatment (4). For women, motivational programs and

treatment programs will need to clearly emphasize the role of treatment in alleviating depression

or other psychological distress. Simultaneously addressing women's psychological problems and

substance use could prevent the misutilization of other health and mental services after release.

Examining the profile of predictors of treatment entry for women within the context of

their characteristics highlights the relevance of social pressures and relationships. Women were

more likely to have a history of physical abuse, to have a diagnosis of depression and report that

they plan to live with minor children after release but were less likely to have positive family ties.

All of these factors are related to treatment entry for women. Addressing issues of high salience

may enhance women's motivation for treatment. Effectiveness of treatment can be increased

through indirect positive effects on the families of these women, most of whom will be

responsible for minor children when released from prison.

Both men and women were less likely to complete the 12-month program as compared

with the 9-month program suggesting the importance of future research to pinpoint a treatment

length and intensity level which is not too difficult to adhere to but yet which results in positive

post-treatment outcomes.

This study increases the understanding of treatment retention by comparing factors that

14
predict treatment entry to those that predict treatment entry and retention. Since levels of drug

use among state prisoners and jail inmates are even higher than in the federal systems, these

findings should also be relevant for drug treatment programs in these other correctional settings.

Many of the same processes which attract individuals to treatment are the same as those which

keep individuals in treatment. Motivation to change leads individuals to enter treatment and also

leads them to remain in treatment. Social ties and external incentives are related to treatment

entry but are also important to treatment retention. If the same factors which lead an individual to

seek help are those which keep an individual in treatment, the focus of research should be on

treatment entry to ensure that those most in need of treatment or who can most benefit from it are

those who receive treatment. However, since the availability of treatment and the treatment

admission process may differ in other correctional settings, other studies may be needed to

identify additional crucial issues surrounding treatment entry.

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 Acknowledgments

This project was funded in part by the National Institute on Drug Abuse through an interagency

agreement with the Bureau of Prisons (BOP MOU-201-0).

William Rhodes from Abt Associates and William Saylor of the Federal Bureau of Prisons

provided statistical consultation for this paper.

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Table 1. Descriptive Statistics for Men and Women Eligible to Enter Residential Drug Treatment
Men Women
White 62.6% 50.9%

Highest grade com pleted (mean # years) 12.1 11.5

Age at time of commitment (mean) 34.0 32.8

Age of first arrest (mean) 21.3 24.2

Severity of offen se - moder ate 42.2% 46.6%

Severity of offen se - greatest 20.6% 9.3%

Average/good family ties 92.8% 84.3%

Employed at time of incarceration 53.3% 37.3%

Not in work force at time of incarceration 3.9% 7.5%

Sentence length (mean # months) 82.3 40.0

History of violence - less than 5 years ago 14.4% 7.2%

No daily drug/alcoho l use 16.5% 13.6%

Daily use of a lcohol only 10.9% 3.7%

Daily use of illicit dr ug - marijuan a only 17.9% 14.0%

Daily use of illicit drug other than marijuana - cocaine, 54.7% 68.7%

heroin, opiates, barbiturates, etc.

Diagnos is of depress ion only 7.9% 19.4%

Diagnos is of antisocial pe rsonality only 28.4% 16.9%

Diagnoses of both depression/ASP 8.1% 13.3%

Neither dia gnosis 55.6% 50.4%

Plan to live with minor children after release 38.2% 60.0%

History of physical abuse before age 18 15.5% 31.3%

Precontemplation (mean) 1.95 1.59

Contemplation (mean) 3.37 3.15

Action (mean) 3.38 3.14

Maintenance (mean) 2.78 2.62

Year off p rovision bu t no time availa ble 18.8% 7.7%

Type o f program 12 mon th (Treatm ent participa nts only) 23.8% 36.7

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Table 2. Predictors of Treatment Entry for Men and Women: Maximum Likelihood Probit Estimation

Men Women
Background Characteristics Est. s.e. Est. s.e.
Race - African American 0.019 0.119 0.476 0.215 *
Race - Other -0.071 0.208 -0.373 0.380
Severity of offen se - moder ate 0.203 0.081 ** -0.375 0.142 *
Severity of offense - high -0.167 0.111 0.054 0.193
Severity of offense - greatest 0.010 0.108 0.324 0.242
Family ties - average/good -0.273 0.089 ** 0.269 0.121 *
Level of education -0.073 0.024 ** -0.096 0.043 *
Employed at time of incarceration 0.056 0.113 0.346 0.186
Not in work force at time of incarceration -0.132 0.201 0.622 0.312 *
Unemployed at time of incarceration -0.029 0.155 -0.239 0.249
Unknown employ. status upon incarceration 0.221 0.305 -0.838 0.440
Drug Use History
Daily use of alcohol only before arrest -0.058 0.138 1.157 0.508 *
Daily use of marijuana (mj) o nly before arrest -0.089 0.111 -0.512 0.254 *
Daily use of mj and other illicit drug(s) before arrest 0.100 0.101 -0.039 0.237
Psychiatric Diagnoses
Diagnosis o f depressio n only 0.005 0.168 -0.475 0.209 *
Diagnosis o f antisocial pers onality (ASP ) only -0.074 0.105 0.270 0.233
Diagnoses of both ASP and depression -0.247 0.156 -0.492 0.227 *
No diagnosis of ASP or depression 0.039 0.096 0.332 0.164 *
Family Characteristics
History of physical abuse before age 18 -0.029 0.074 0.217 0.107 *
Plan to live with minor children after release 0.148 0.057 ** 0.246 0.102 *
Internal Motivation (Pro chaska’ Change A ssessment)
Precontemplation -0.495 0.091 ** -0.622 0.181 **
Contemplation 0.642 0.178 ** 0.556 0.324
Action -0.032 0.170 -0.445 0.290
Maintenance 0.310 0.106 ** 0.497 0.211 *
External Incentive - Sentence Reduction
Year off - no time -0.593 0.205 ** -0.309 0.247
Year off - 1 to 5 months -0.492 0.149 ** -0.319 0.177
Year off - 5 to 12 months -0.026 0.165 -0.238 0.208
Type of program
12 month program 0.113 0.072 -0.427 0.152 **
Constant -0.641 0.619 0.590 1.081

* p<.05 ** p<.01

18
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